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An Affiliate of the National Guardianship Association
North Carolina Guardianship Association
North Carolina Guardianship AssociationNorth Carolina Guardianship Association
North Carolina Guardianship Association
Post Office Box 17673 Raleigh, North Carolina 27619
Phone: (919) 266-9204 Fax: (919) 266-9207
Email: ncgu[email protected]m Website: nc-guardian.org
APPLICATION FOR CERTIFIED GUARDIAN
(Must be completed and notarized)
1. Full Name: ___________________________________________________________________________
(As you wish it to appear on your certificate)
2. Are you a member of the North Carolina Guardianship Association? Yes _________ No _________
3. Business/Agency Name (if applicable): ____________________________________________________
4. Mailing Address: ______________________________________________________________________
City: ______________________ State: ______ Zip Code: ___________ County:___________________
5. Daytime Telephone Number: ________________________ Fax Number: _________________________
6. Evening Telephone Number: ________________________ E-mail Address: ______________________
7. Education:
High School Diploma (or GED) ___________________________ Year Awarded _________________
High School or Certifying Body: ___________________________ City/State ____________________
College/University Degree: _______________________________ Year Awarded ___________________
College/University _________________________________________ City/State___________________
College/University Graduate Degree ________________________ Year Awarded _________________
College/University _____________________________________ City/State_______________________
8. List your experience providing guardianship or other related work experience, beginning with the most recent:
Employer Name/Address Position Start and End Dates
______________________________________ __________________________ ________________
_____________________________________ __________________________ ________________
______________________________________ __________________________ ________________
______________________________________ __________________________ ________________
List volunteer experience:___________________________________________________________________
________________________________________________________________________________________
List experience serving family member or friend with special needs:__________________________________
_________________________________________________________________________________________
Additional comments/clarification __________________________________________________________
______________________________________________________________________________________
9. Guardianship Education and Related Courses (Please attach a listing of dates, courses taken, course sponsors,
locations and the number of hours completed for each course within the last two years with appropriate
documentation.)
North Carolina Guardianship Form
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